The inspection, filed as a complaint survey, was completed September 3, 2025.
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The resident who didn't return was identified in the inspection report only as Resident 5.
The call light cord belonging to Resident 4 had been pulled from the wall.
At Carmel Mountain Rehabilitation & Healthcare Center, a licensed nurse learned at 9:30 a.m.
Thirteen days later, she fell again.
The date written on the dressing did not lie.
The Maintenance Director confirmed it himself.
The resident, identified in inspection records only as Resident 150, was admitted July 14 and discharged July 16.
The instructions were specific and time-limited.
Federal inspectors discovered the boxes during a complaint inspection on September 3, 2025.
The resident, identified in inspection records only as Resident #2, was admitted to the facility in January 2023.
She understood exactly what had happened and exactly what she had been told.